 The next item of business is a statement by Shona Robison on response to Audit Scotland NHS 2016 report and service development. The cabinet secretary will take questions at the end of her statement and therefore there should be no interventions or interruptions. I call on Shona Robison, a tight 10 minutes please cabinet secretary. Thank you, Presiding Officer. I'll today outline the Scottish Government's response to last week's Audit Scotland report and the process of considering those proposed service changes and developments that were debated on 28 September. Audit Scotland has provided a balanced overview of the NHS and makes several recommendations that we accept in full. Our NHS cannot stand still and must continually evolve to deliver the best medicine and the best care but also to ensure that public money is spent as effectively as possible. Our clear vision to achieve this change has been acknowledged by the Auditor General who said last week that the Scottish Government has, quote, "...a real vision to reshape services." Our strategy is founded on our twin approaches of investment and driving reform and we have made significant investments in our NHS. Since 2010-11, the annual health resource budget has increased by 8.2 per cent in real terms. The Audit Scotland report recognises the real terms increases in investment in our NHS and this Government will go further to ensure that the NHS receives the resources that it needs to be equipped for the future. For example, we are increasing the NHS revenue budget by £500 million over inflation over this Parliament. However, it is important to invest more than money and it is imperative that we drive reform. As well as progress with integration, we have taken other steps this year to accelerate the shift in care and to develop and reform the delivery of health and care services. Increasing demands means that we are accelerating change. We have shifted more NHS funding to support social care, published a national clinical strategy on the CMO's realistic medicine report, accelerated plans for investment of £200 million in our new elective centres and are reviewing targets and indicators through work being led by Sir Harry Burns. As part of a plan to increase health spending by almost £2 billion by the end of this Parliament, we will take the share dedicated to primary services to 11 per cent of front-line NHS spending. We will increase our investment in primary care by an additional £500 million, helping to shift the balance of care and having, for the first time ever, at least half of our front-line NHS spend being invested out with acute hospitals. Despite the challenges that our NHS is performing well and staff are to be thanked for working to address the increase in demand for services, we now have almost £1.5 million new outpatient attendances every year. That is up over 13.2 per cent under this Government. Since 2005-06, there have been 25 per cent more hit replacements that are being carried out, but waiting times have reduced by 50 per cent. For cataracts, we are seeing a 30 per cent increase in procedures with a 40 per cent reduction in waiting times. We know that more patients than ever before are being treated for cancer, with an increase of over 1,000 patients per quarter now being included in the 62-day cancer waiting time standards compared to earlier in 2010. Performance against the 62-day standard is lower than we want, which is one of the reasons why we are investing £100 million over the next five years to improve cancer care. Plus, Scotland's core A&E departments have been the best performing in the UK for at least the last 18 months, outperforming England by almost eight percentage points in August 2016. The Audit Scotland report confirms that NHS staffing is at historically high levels, with more than 11,000 more staff working in our health service than there were when we took office. We are also acting to ensure that our medical workforce grows further, making it more sustainable and increasing the number of undergraduate medical school and specialty training places, as well as creating a new graduate entry medical school. We are working to establish national and regional workforce planning, which will help to deliver the direction that is set out in our national clinical strategy and to protect our commitment to no compulsory redundancies. Through that, we will work to address the cost of supplementary staffing, including efforts towards recruiting permanent posts when they are required and reducing agency spend. We will also use those workforce planning efforts to make better use of a staff bank system and framework contract when supplementary staff are needed. As I have already said, we have consistently prioritised investment in the NHS and have increased front-line health spend, and we will continue to prioritise front-line health services as we go on to increase the NHS revenue budget by £500 million more than inflation over the course of this Parliament. NHS territorial boards received a 5.5% increase this year compared to 2015-16 budget levels. That comprises an increase for front-line services of £224 million, delivering an above-inflation increase and an additional £250 million when the new health and social care partnerships are using to invest in social care under our arrangements for integration. We will consider the Audit Scotland proposal for three-year budget management within our work to examine how to provide NHS boards with more financial flexibility and, in the context of the accounting and financial management framework set out by the Treasury. Despite the record level of resource, we recognise the challenge of meeting increased demand. As the Auditor General has made clear in her report, more needs to be done than simply giving the NHS extra money, which is why our plans for change are so important. I can confirm that by the end of this year we will set out in a single framework a transformational change delivery plan, which will bring together the different strands of reform that I have already set out, and I will keep Parliament informed of the progress being made. Moving to service developments, Audit Scotland has been clear that some reorganisation of services will be required, but that does not mean that every proposal made by every board will be approved. We are committed to robust evidence-based policy making that delivers better outcomes. However, to stand against any change anywhere in acute services is simply not credible. Where change is advocated, we must ensure that local boards work with all stakeholders to explore any issues and benefits, and I want to reiterate that any major change proposals must be subject to formal public consultation and ministerial approval. Within that, I will take the opportunity to update Parliament on the specific service changes debated last month. On cleff surgery, the recommendation endorsed by the Royal College of Surgeons to consolidate on a single site in Glasgow is distinct in the sense that it relates to a specialist national service as opposed to a local service. As such, I am now considering the proposal in line with the president of ministers making the final decision on national specialist services. I have met the clinical teams in both Glasgow and Edinburgh, and in the light of these discussions and giving full consideration of the evidence, I expect to make a decision before the end of the year. NHS Lanarkshire's longer-term plans as part of their local clinical strategy have been designated as a major change by the board. Boards can choose to designate proposals as major and follow the appropriate process without the need to ask ministers. Those plans were subject to formal public consultation between 2 August and yesterday. The board intends to consider the outcomes of that at their meeting on 30 November, informed by the report of the Scottish Health Council on the consultation. Any board decision made on associated specific major change service proposals will then be subject to my approval. What is beyond question is that all three acute hospitals will retain their A and E departments for the benefit of local people. The NHS Greater Glasgow and Clyde board agreed at its meeting on 18 October that their proposals on paediatric services at the Royal Alexander hospital should be designated major. The board will now undertake three months of formal public consultation due to begin next Monday. The board is scheduled to consider the outcomes of that by spring of next year, as informed by a report on the consultation by the Scottish Health Council. Any board decision made on those service change proposals will then be subject to my approval or otherwise. In terms of the remaining proposals from NHS Greater Glasgow and Clyde, those affecting deliveries at the community maternity units at the Inverclyde Royal hospital and the Vale of Leven hospital, those affecting inpatient care at the Centre for Integrative Care and those affecting Lightburn hospital are all subject to on-going public engagement. That cannot be prejudged as it is possible that some or all of the proposals may change as a result and some may not proceed at all. The Scottish Health Council continues to monitor the engagement activity and will offer a view on the designation of the proposals at the end of the activity, likely to be in early December. Ministers will then carefully consider their views on designation from both the health board and the health council and come to a decision. The board will then consider the next steps, as informed by the designation decisions at its meeting on 20 December. Presiding Officer, while I will not prejudge those proposals, I would want to reiterate that they must be consistent with national policy, such as a review of maternity services due for publication soon. I would also want to put on record once again this Government's commitment to the vision for the Vale of Leven and to say that any final proposals for Lightburn must address the concerns that led to our previous decision in 2011. I will keep Parliament informed as further progress is made with those proposals. In conclusion, Presiding Officer, I believe that there is a clear case to further shift from acute to primary and community services. I am confident that there is a broad consensus on this and that the Audit Scotland report supports that view. Certainly, so far no one and no party in this chamber has brought forward an alternative way forward. I believe that this consensus can be underpinned by the mutual recognition that our NHS continues to require increased investment and that it must reform to ensure that it means true to its founding principles, publicly owned and free at the point of need. I am happy to take questions on my statement. We will now move to questions. Time is very, very tight, so at the shorter the questions and answers, the more members will be able to take part. Please press your request to speak buttons. I call on Donald Cameron to be followed by Anna Sarmer. Thank you, Deputy Presiding Officer. I would like to thank the cabinet secretary for early sight of her statement. We clearly have a debate on the report later, so I will keep my observation short. There is much in the statement that was not new, but it is important to state that since the SNP first entered office almost 10 years ago, Audit Scotland has argued that a shift from traditional means of delivering services to community-based services is required to change the way that services are delivered. Almost every single Audit Scotland report since has noticed that progress has been slow or non-existent. Funding has not been transferred from acute services to community-based services at the rate that it should be. We welcome the announcement to shift the balance of care towards primary care. The fact remains that it has taken far too long for this Government to take action. It should not require, in this session at least, two opposition debates and a damning public report to spur the Scottish Government into taking steps. I ask two questions of the cabinet secretary. On workforce planning, NHS staffing is clearly an issue that, on this side of the chamber, we have concentrated on. Will the Scottish Government commit to publishing a national workforce plan immediately and commit to presenting an update to the Scottish Parliament every six months? Secondly, can I ask the cabinet secretary, in light of her announcement that a share of primary services spending will rise to 11 per cent of front-line NHS spending? How much of that will go specifically to general practice? Shona Robison I thank Donald Cameron for his questions. He talks about the time that it has taken to shift the balance of care. It is a challenge and it is a difficult thing to do. I think that all health systems would acknowledge that. However, one of the big achievements of this Government in moving towards the shift of balance of care has been, of course, the integration of health and care services. It is one of the biggest reforms that we have seen in the public sector in a generation. Although I accept that the pace needs to be increased, I think that it should be recognised that that has been a substantial leap forward in shifting the balance of care through the integration of those services. In terms of workforce planning, we have already set out our plans to develop national and regional workforce plans. We will be publishing a discussion document because stakeholders want to be involved in that. We will be doing that by the end of the year. I am happy to take on board his suggestion about six-monthly updates. I am happy to look at that, whether that can be delivered and if it can. We will do that. In terms of the primary care services, I am sure that he will, as well as I do, welcome the announcement that the First Minister made to increase the share of spend on primary care services. That will mean change, though, because it will mean having to up and increase the shift in the balance of care from acute services in order to deliver that shift in balance to primary care services. He will recognise, as well as I do, that it is not just about investing in general practice, although we will do that. He knows that we are working on a new contract with the BMA. It is also about that wider primary care team. The workforce plans that we will set out will address not just general practice, but that wider primary care team in taking that plan forward. Anas Sarwar, to be followed by Fulton MacGregor. I thank the cabinet secretary for a prior sight of the statement, but the truth is that the cabinet secretary has been dragged kicking and screaming to this chamber because, a week after the worst state of the NHS report since devolution, the cabinet secretary has before us, armed only with warm words. No recognition of the crisis in the NHS, no acceptance of our Government's role and the failures, no plan to reverse the damaging cuts to front-line services and a Government letting down the staff and patients in our NHS. While I will focus on audit Scotland in the debate later, I want to focus my remarks on the proposed service changes. The reality is that this is disappointing that the health secretary has chosen not to accept the will of Parliament in this statement today, because in actual fact she says nothing new. There is no comfort for those communities facing the loss of vital local services and valued local input. I will give one example. How can the cabinet secretary come to this chamber and say that a hospital closure—not a ward closure, not a downgrade of services, but the complete closure of Lightburn hospital—is not a major service change? Mr Sarwar, you are almost at the end of your time and you have not asked a question yet. I am just coming to the question, Deputy Presiding Officer. What we have is a minister who is clearly out of her depth. On GMS on the day of the Audit Scotland report— Mr Sarwar, could you ask a question, please? It is my question, Deputy Presiding Officer. The health secretary said that Labour was putting blocks in the way of any service changes in Parliament. So can the cabinet secretary now clarify which service changes she was referring to, and if that every promise that her party made before the election about local NHS services will be kept? I think that Anna Sarwar's contribution to the debate shows that he has nothing to say other than just personal abuse. That is a thin pig leaf for having nothing to say about the NHS. In terms of the Audit Scotland report, unlike Anna Sarwar's contribution, it was a balanced report. It recognised some of the achievements that have been made by the staff, the hard-working staff in our NHS, unlike Anna Sarwar's contribution. We have the right strategies in place. Audit Scotland says that we do. The opposition, Anna Sarwar, has no plans, no alternative vision for the NHS. We have the vision, we have the strategies. Audit Scotland says that they are the right ones. In terms of the will of Parliament, I have come here today and I have laid out the decisions that I will make on those service change proposals that are coming to me. In terms of light burn, it may well be a major service change proposal, it is just that we are not at that stage at the moment. If it does get to that stage, then it will come to me for decision. I have made very clear in my statement that, on 20 December, Glasgow will decide which service change proposals, if any, they are continuing with. It would be wrong to call in a service change proposal that, at the moment, might not even exist. I would have thought that even Anna Sarwar would understand that part of the process. I suggest that Anna Sarwar goes back and does his homework perhaps come back to this chamber a little more informed than he has today? Can I say to the chamber that when front benchers overrun their time, all that it does is penalise their colleagues? The Scottish Government announced a review that was chaired by former chief medical officer Sir Harry Burns into health and social care targets and indicators, which has been advocated by the BMA, RCN and medical colleagues. Can the cabinet secretary confirm that certain performance targets, such as 95 per cent of patients being seen in A and E within four hours, and cancer treatment targets will be retained within that wider work? As I said previously, the work of Harry Burns in reviewing the targets is very, very important. One that has the support of the majority of the chamber, because it is very important that we look at the outcomes for patients and that our targets better reflect those outcomes for patients. That is something that the royal colleges support and many stakeholders support. In going forward, I have made a couple of things very clear. One is that, on cancer, we believe that it is very important that the cancer targets improve the care and treatment for cancer patients. That is why we are investing £100 million of additional money over the next five years. We would expect any review of cancer targets to reflect our ambitions to improve the care and treatment for cancer patients. On A and E targets, the four-hour target, I have said previously that the Royal College of Emergency Medicine feels quite strongly about that. The four-hour target is a barometer of how the whole hospital is performing. I would take some persuading away from the four-hour target, but it might be that it can be made more sophisticated in nature. That is something that I am sure that Harry Burns will look at. Miles Briggs, followed by Clare Haughey. I thank the cabinet secretary for an advanced copy of her statement. The Audit Scotland report has NHS Lothian's financial position as a case study on page 15. Given that NHS Lothian, Tayside and NHS 24 all continue to face major financial difficulties, what assurance has the cabinet secretary been given that this is not impacting on patient care? With regard to cleft surgery, the Royal College of Surgeons does support the principle of centralisation, but it has said that it is not in its role to advise on a location. Something that the cabinet secretary's statement is clearly misleading on. Can I ask her to correct that? Shona Robison Miles Briggs said that the uplift to NHS Lothian for 2015-16 was 6.4 per cent. NHS Lothian has been an NRAC beneficiary in terms of the resources going forward. However, I recognise some of the challenges within NHS Lothian. My officials have been working very closely with NHS Lothian to address some of their outpatient weights, for example, and I will have more to say about initiatives around improving outpatient performance in a few weeks' time. On cleft surgery, I have laid out very clearly that that decision has now come to me. The college's view has been made very, very clear indeed. I had a very productive meeting with the Glasgow surgeons and, indeed, the Edinburgh surgeon and her team. What I want to do now is to look at all of that and come to the right conclusions about what is in the best interest of patients across the whole of Scotland. I hope that Miles Briggs will appreciate that that is the founding principle of my decision going forward. Staff banks can provide boards with access to a pool of appropriate trained non-agency staff who can provide short-term supplementary cover when required. I am sure that the cabinet secretary will join me in commending those who give of their time in this way to fill in, often at short notice. Can the cabinet secretary outline what percentage of total nursing and midwifery staff in the NHS in Scotland is represented by agency staff and what the Scottish Government is doing to reduce the reliance on agency staff? Jenny Marra followed by Bob Dorris. I am so determined to get through these and let other people in. Can I answer Clare Roy's question firstly by commending the work of all staff across our NHS. She makes an important point. Agency nursing represents about 0.4 per cent of the total nursing and midwifery staffing in the NHS in Scotland, so it is proportionally very small. However, it is still too high and that is why we have a programme of work under way nationally working with boards to look at how we have a more effective management of all temporary staffing. We are working with boards to reduce reliance on the costs of temporary agency and bank staffing. The team are ensuring that, when temporary staff are required, the agency is the very last resort. As part of that, we have implemented monthly agency spend reporting to make sure that boards are informed of their spend and know where to focus their attention in addressing it. May we now have Jenny Marra followed by Bob Dorris? Spending on agency staff is certainly too high, cabinet secretary, and NHS Tayside. You will know from the Audit Scotland report just published. Spending on agency staff in Tayside has increased by 39 per cent just over the last year. Can the cabinet secretary please tell me how the framework contract in her statement will assist this critical overspend in NHS Tayside? Shona Robison As Jenny Marra makes an important point, there are big disparities between the spend on agency staff between boards. Some are spending far higher than other boards and that is something that we are absolutely wanting to address and are working with Tayside to address. There are some regional variations and some boards find it harder to recruit permanent staff but without bearing down on agency costs are critical here. We have made it very clear to the management team in Tayside that we expect them to do that as a matter of priority, but we will help them to do that. Part of the solution is converting some of those that agency spend into substantive posts and helping boards to do that. The work that I have announced in terms of the delivery plan going forward and the workforce element of that, both the national workforce plan and the regional workforce plan, will also help us to plan the numbers of nursing and midwifery posts that are required going forward so that we can make sure that we have the right training places and that we have the right numbers in the right places to support that. I am very happy to keep Jenny Marra updated around the work that we are going to take forward with Tayside specifically. Bob Doris, followed by Alison Johnstone. Alison Johnstone Cabinet Secretary, Audit Scotland highlights in its report that the grid of Glasgow has an impressive record on key NHS indicators, such as treatment time guarantee, referral to outpatient appointment, as well as a 30 per cent fall in bed days lost via delayed discharge. However, its A and E performance was not impressive compared to other Scottish boards. How do we use that report to ensure that best practice is shared between boards to ensure that we constantly drive up standards and performance? Shona Robison Bob Doris raises some important points. The 30 per cent fall in bed days lost in Glasgow has been very impressive. We have been looking at what Glasgow has done with its partners, and we are keen that other partnerships, and to get you partnerships, follow suit to address the best ways of reducing delay. We know what works, and we want other partnerships to follow what works. I think that Glasgow has led the way on that. In terms of the A and E performance, Bob Doris will be aware that a huge programme of work in delivering six essential actions is the six things that we know have to be done in order to improve A and E performance across the board. I think that the performance over the last 18 months, the fact that it is the best across the whole of the UK and has dramatically increased and improved, shows that that programme of work, those six essential actions, has worked. Glasgow has had more of a challenge, and there have been particular challenges at the Queen Elizabeth and the Glasgow Royal Infirmary. My team of officials have been working very, very closely with Glasgow to address those issues. I am very confident that that work will bear fruit and that Glasgow's performance will improve. Alison Johnstone Investment in prevention is key to reducing increased demand for NHS services. Can I ask the cabinet secretary what action the Scottish Government is taking to develop a truly integrated public health strategy, as called for in Audit Scotland's report, as today's statement hasn't addressed the urgent need for a truly integrated new public health strategy with a focus on prevention at all? Alison Johnstone makes an important point about prevention. She will be aware of the review of public health and the fact that we will now have a new public health strategy going forward. I am keen that that public health resource, and we are looking at how best to consolidate that public health resource to be able to deliver a service not just to the NHS but to the rest of the public sector local government in particular, to help decision makers to make the right decisions based on the data and what the evidence tells us about the needs of the local population. More importantly, what programmes within public health and prevention will work to keep people out of our hospitals and to stop them falling ill in the first place. I am very happy to keep Alison Johnstone updated on the progress of that new public health strategy and, indeed, bringing the public health resource into the one place and the benefits that I think that that will deliver. I call Brian Whittle, and if he's very quick, I can call Colin Smith. Thank you, Deputy Presiding Officer. I was disappointed in the Cabinet Secretary's statement that there was not one mention of tackling the alarming rise of serious preventable disease epidemic. Can I ask the Cabinet Secretary when is this Government going to give proper thought and attention to a sustainable plan to address the prevention of ill health and growing health inequality? As I have just answered to Alison Johnstone, Brian Whittle will appreciate that there has been a huge amount of work that has gone into the review of public health, which will help us to not just bring the public health resources and workforce together into a more coherent fashion, but to make sure that that then delivers some of the changes that Brian Whittle is talking about. Those changes cannot be delivered by the NHS itself. That is about, across the whole of the public sector, not least involving local government. I am very keen that we give prevention and public health more of a focus. I think that the review has helped us to find a way forward to doing that. Again, I am very happy to keep Brian Whittle updated of the progress of that going forward. The audit Scotland report describes the cuts facing health boards as unprecedented. £293 million for 2015-16 has risen to £492 million for 2016-17. Does the cabinet secretary still believe that those cuts are merely efficiency savings, and is she prepared to say to the chamber today that not a single penny of those cuts, not a single measure taken to meet those cuts, will impact adversely on patient care? Shona Robison By the end of this Parliament, we will have increased health funding by almost £2 billion, building on the £3.3 billion increase that is already delivered under this Government. By the end of this Parliament, health funding will be at least £500 million more than inflation only increases. That was the highest offer of any party in this chamber, including your party. Your party had the lowest offer of health funding out of all the parties. Please, could you close now, cabinet secretary? I will take no lessons from the Labour Party about health funding. What is important, though, is not just the amount of money going into the NHS, but what that money is spent on, which is why we need to shift the balance of care with additional £500 million into primary care by the end of this Parliament. I hope that those plans will get the support across this chamber. Shona Robison The Parliament has had since the damning publication of the Audit Scotland report last week, yet we have had five sycophantic questions from the Government benches to pad out the time and we have not been able to call every party in this place. Can we please extend the time? Mr Cole-Hamilton, we had six Opposition questions and three Government questions. If that is an issue, please take it up with your business manager, where there can perhaps be discussion among all parties about asking questions rather than making statements and giving the courtesy to their backbench colleagues to allow them all to take part. There is a debate on the same subject later this afternoon, and history on it will not change my mind.